Outline

Objective: There is growing amount of patients with osteoarthritis of hip, knee or another joint with prior coronary intervention and drug-eluting or bare-metal stents demanding lifelong anti-platelet therapy. Nowadays these patients want to undergo orthopaedic surgery like arthroplasty as well to relieve their pain. Perioperative Managemnet of these patients has to balance the risk of bleeding versus stent thrombosis.

Until recently evidence-based studies are lacking on which to base a consensus for the peri-operative management of these patients undergoing elective orthopaedic surgery. There are two distinct antithrombotic management strategies illustrating the higher risk of either approach-bleeding and the need for blood transfusion versus higher risk for in-stent thrombosis and myocardial infarction.

Methods: We searched Pub Med in November 2009 with the key words “orthopaedic AND anti-platelet therapy” and got eight teen hits. Furthermore we searched for related articles and got additional twenty-seven hits. We furthermore evaluated German-speaking journals and found thirty-one additional publications dealing with this problem.

Results and conclusions: Until now data regarding the perioperative management of anti-platelet agent-treated patients undergoing orthopaedic surgery are scarce. There is still a well established opinion in many European orthopaedic and traumatologic departments to pause anti-platelet-therapy seven days before surgery until about ten days after surgery although recent literature is recommending continuous anti-platelet-therapy in patients undergoing orthopaedic surgery. A close collaboration between anaesthesiologist, cardiologist and surgeon is essential for appropiate pre-, intra- and postoperative mangement.

Hence we created a decision tree based on the international literature how to deal with these cardiovascular patients at risk at our orthopaedic department to establish a consensus paper and want to present it to a broad auditorium to provoke brainstorming and interdisciplinary discussion.

Patients with bare-metal coronary stents should whenever possible be delayed to elective surgery for at least 4 to 6 weeks to allow partial endothelialization.Elective operations concerning patients with drug-eluting stents (DES) should be deferred until they have completed a period of 12 month dual anti-platelet therapy. Patients with DES who have to undergo surgery within that crirical time frame should continue aspirin while the thienoyridine therapy should be paused for 5 days pre-and postoperatively.